Analysis Vessel Capsizing The OceanTor was likely experiencing water ingress via the shaft tunnel, which may also have progressed into the engine room. The resulting loss of freeboard and reserve buoyancy significantly diminished the vessel's righting ability. The situation was exacerbated by the fluctuation in buoyancy forces as the vessel moved through wave crests and troughs, and the rise in centre of gravity as a result of lifting the net with the cargo boom. At this point, the vessel was unable to overcome the heeling forces. When it capsized, seawater downflooded through the hatches, and via open doorways to other spaces until, approximately two days later, the vessel lost all reserve buoyancy and sank. Bilge Monitoring and Pumping The shaft tunnel was vulnerable to water ingress via the propulsion shaft stuffing box. Water collecting there would not be noticeable to anyone in the engine room until, once the level of the transverse floors was reached, it eventually spilled over. In addition, the system in place to protect from water ingress into the space was itself vulnerable. Without a guard in place, the location of the switch meant the power to the small stuffing box pump could be inadvertently shut off by someone brushing past. If, in addition, the alarms were not functioning or were not heard, it is likely that no one would recognize the problem, as had happened on a previous occasion. Decision to Fish The OceanTor was operating with a crew of three, rather than the minimum of five stipulated on the inspection certificate. This meant the master had to leave the wheelhousethe vantage position from which to supervise and ensure vessel safetyunattended to help with operations on deck. Similarly, rather than focussing on the safe operation of the engine room and related machinery, the engineer was also busy performing tasks related to the fishing operations. The result was that both senior supervisory personnel were distracted from their main duty, that of ensuring vessel safety, and were busy dealing with the stowage of the catch. Following the fifth tow, crew members, including the master, noticed that the vessel was unusually low in the water despite having only some 61000kg of fish on board. However, the risk was not fully appreciated and fishing continued with compromised safety margins. Stowage of Liferafts In this occurrence, the liferaft became trapped when it was deployed, its painter caught in the rigging. As is the case on most fishing vessels, the OceanTor's liferaft had been placed on top of the wheelhouse due to a combination of space limitations on deck and the need to have an unobstructed work area for fishing operations. Although practical from an operational point of view, storing liferafts this wayclose to booms, rigging and/or railingsmay impede their safe launch and, consequently, evacuation during emergency abandonment. Should a raft or its painter become entangled, there is increased risk of damage to the liferaft and injury to the crew. This issue has been raised in several other TSB reports involving small fishing vessels.6 TC has issued Ship Safety Bulletins (SSBs) 09/1993 and 03/2001. Both of these SSBs address recommendations on the stowage of inflatable liferafts. A new SSB, 07/2007, was issued in August2007. It reiterates TC's recommendations regarding the optimum stowage of liferafts and advises owners of TC's intention to amend requirements concerning float-free arrangements. The OceanTor likely experienced ingress of water into the shaft tunnel, which progressed into the engine room. The resulting loss of reserve buoyancy, exacerbated by the rise in centre of gravity when the net was lifted, left the vessel unable to overcome the heeling forces of the seaway, culminating in the capsizing. Once the vessel capsized, seawater downflooded via open doorways, vents, and other deck openings until the vessel eventually sank. The vessel had insufficient crew, and both senior supervisory personnel were busy dealing with the stowage of the catch rather than ensuring vessel safety. The risk to the vessel's stability was not fully appreciated, and fishing continued with compromised safety margins.Findings as to Causes and Contributing Factors The OceanTor likely experienced ingress of water into the shaft tunnel, which progressed into the engine room. The resulting loss of reserve buoyancy, exacerbated by the rise in centre of gravity when the net was lifted, left the vessel unable to overcome the heeling forces of the seaway, culminating in the capsizing. Once the vessel capsized, seawater downflooded via open doorways, vents, and other deck openings until the vessel eventually sank. The vessel had insufficient crew, and both senior supervisory personnel were busy dealing with the stowage of the catch rather than ensuring vessel safety. The risk to the vessel's stability was not fully appreciated, and fishing continued with compromised safety margins. Placing liferafts near booms and rigging can impede their safe launch, as well as the subsequent evacuation of crew during an emergency abandonment.Finding as to Risk Placing liferafts near booms and rigging can impede their safe launch, as well as the subsequent evacuation of crew during an emergency abandonment. The power to the independent stuffing box pump on board the vessel was vulnerable to being inadvertently shut off when people brushed past the switch.Other Finding The power to the independent stuffing box pump on board the vessel was vulnerable to being inadvertently shut off when people brushed past the switch. Safety Action Action Taken Transport Canada (TC) issued a new Ship Safety Bulletin (SSB), 07/2007, in August2007. It reiterates TC's recommendations made in SSBs 09/1993 and 03/2001 regarding the optimum stowage of liferafts and advises owners of TC's intention to amend requirements concerning float-free arrangements.